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Background: The ventilation bundle has been used in adult intensive care units to decrease harm and improve quality of care for mechanically ventilated patients. The ventilation bundle focuses on prevention of specific complications of mechanical ventilation; ventilator-associated pneumonia, sepsis, barotrauma, pulmonary oedema, pulmonary embolism, and acute respiratory distress syndrome. The Institute for Healthcare Improvement ventilation bundle consists of five structured evidence-based interventions: head of the bed elevation at 30-45°; daily sedation interruptions and assessment of readiness to extubate; peptic ulcer prophylaxis; deep vein thrombosis prophylaxis; and daily oral care with chlorhexidine., Objectives: The objective of the study was to evaluate the use of the ventilation bundle in two intensive care units in Victoria, Australia., Methods: This is a 3-month prospective observational study in two intensive care units. Patient medical records were reviewed on days 3, 4, and 5 of mechanical ventilation using a prevalidated ventilation bundle checklist., Results: A total of 96 critically ill patients required mechanical ventilation for more than 2 d. Patients had a mean age of 64.50 y (standard deviation = 14.89), with an Acute Physiology, Age, Chronic Health Evaluation (APACHE) III mean score of 79.27 (standard deviation = 27.11). The mean ventilation bundle compliance rate was 88.3% on the three consecutive mechanical ventilation days (day 3 = 79.4%, day 4 = 91.1%, and day 5 = 96.7%). There was a statistically significant difference in the mean APACHE III score between patients who had head of bed elevation and those without head of bed elevation, on days 3 (p = <0.001) and 4 (p = 0.007)., Conclusion: The ventilation bundle elements were used in Australian intensive care units. The likelihood of having all ventilation bundle elements on day 3 was low if the patient's APACHE III score was high. However, the ventilation bundle compliance rate increased with mechanical ventilation days., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

Purpose: Patient safety has developed as a strong marker for healthcare quality. Safety matters are important in the intensive care unit (ICU) where complex clinical decisions are made, intensive technology is used, and families hold a unique role. The aim of this review was to identify and describe factors that influence family member's perceptions of safety in the adult ICU., Data Sources: Searches were conducted between September and November 2018 and repeated in July 2020 using CINAHL, MEDLINE (EBSCO), PubMed and PsycINFO databases., Study Selection: Published primary studies undertaken in adult ICUs and involving adult family member participants exploring safety or feeling safe. No date restrictions were applied., Data Extraction: A data extraction form collected information about sample, study design, data collection methods and results from each paper. Methodological quality was assessed using the QualSyst tools for qualitative and quantitative studies. Narrative synthesis was undertaken., Results of Data Synthesis: Twenty papers were included with 11 papers published since 2010. The majority of papers reported on qualitative studies (n = 16). Four factors were identified that influenced whether family members felt that the patient was safe in ICU: family visiting, information and communication, caring and professional competence., Conclusion: In detailing specific practices that make families feel safe and unsafe in ICU, these review findings provide a structure for clinicians, educators and researchers to inform future work and gives opportunity for the family role in patient safety to be reconsidered., (© The Author(s) 2020. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: To examine attitudes to patient safety in two intensive care units from the perspective of health care professionals in Saudi Arabia., Background: Despite adverse errors leading to poor patient outcomes, there is a paucity of literature, including staff perceptions, on adverse errors in Saudi Arabian intensive care units., Methods: A descriptive cross-sectional design was used. Health professionals (n = 144) completed the safety attitude questionnaire-intensive care unit., Results: The scores from the six safety domains of the safety attitude questionnaire-intensive care unit showed all respondents had a negative attitude towards patient safety, with participants in one intensive care unit scoring lower in all domains. The mean scores across all domains ranged from 47.1 to 70.3 on a 100-point scale, with the lowest score reported in the "perceptions of management" domain. Respiratory therapists reported a significantly higher job satisfaction score than nurses, and physicians rated communication amongst themselves and nurses as high., Conclusion: There are significant challenges for safety culture in this study, with negative attitudes across all domains., Implication for Nursing Management: Managers may need to review and consider policies relating to safety culture including workforce planning, leadership and patient centred care. Further research into this global health priority is required to contribute to improving patient safety in intensive care units., (© 2017 John Wiley & Sons Ltd.)

Background: Quality ICU end-of-life-care has been found to be related to good communication. Handover is one form of communication that can be problematic due to lost or omitted information. A first step in improving care is to measure and describe it., Objective: The objective of this study was to describe the quality of ICU nurse handover related to end-of-life care and to compare the practices of different ICUs in three different countries., Design: This was a descriptive comparative study., Settings: The study was conducted in seven ICUs in three countries: Australia (1 unit), Israel (3 units) and the UK (3 units)., Participants: A convenience sample of 157 handovers was studied., Methods: Handover quality was rated based on the ICU End-of-Life Handover tool, developed by the authors., Results: The highest levels of handover quality were in the areas of goals of care and pain management while lowest levels were for legal issues (proxy and advanced directives) related to end of life. Significant differences were found between countries and units in the total handover score (country: F(2,154)=25.97, p=<.001; unit: F(6,150)=58.24, p=<.001), for the end of life subscale (country: F(2, 154)=28.23, p<.001; unit: F(6,150)=25.25, p=<.001), the family communication subscale (country: F(2,154)=15.04, p=<.001; unit: F(6,150)=27.38, p=<.001), the family needs subscale (F(2,154)=22.33, p=<.001; unit: F(6,150)=42.45, p=<.001) but only for units on the process subscale (F(6,150)=8.98, p=<.001. The total handover score was higher if the oncoming RN did not know the patient (F(1,155)=6.51, p=<.05), if the patient was expected to die during the shift (F(1,155)=89.67, p=<.01) and if the family were present (F(1,155)=25.81, p=<.01)., Conclusions: Practices of end-of-life-handover communication vary greatly between units. However, room for improvement exists in all areas in all of the units studied. The total score was higher when quality of care might be deemed at greater risk (if the nurses did not know the patient or the patient was expected to die), indicating that nurses were exercising some form of discretionary decision making around handover communication; thus validating the measurement tool., (Copyright © 2014. Published by Elsevier Ltd.)

The use of physical restraint has been linked to delirium in ICU patients and a range of physical and psychological outcomes in non-ICU patients. However, the extent of restraint practice in ICUs is largely unknown. This study was designed to examine physical restraint practices across European ICUs. A prospective point prevalence survey was conducted in adult ICUs across European countries to examine: physical and chemical restraint use during the weekend and weekdays, reasons for physical restraint use, timing of restraint use, type of restraint used and availability of restraint policies. Thirty-four general (adult) ICUs in nine countries participated in the study providing information on 669 patients with details of physical and chemical restraint use in 566 patients. Prevalence of physical restraint use in individual units ranged from 0 to 100% of patients. Thirty-three per cent of patients were physically restrained; those that were restrained were more likely to be ventilated (χ(2)=87.56, p<0.001), sedated (χ(2)34.66, p<0.001), managed in a larger unit (χ(2)=10.741, p=.005) and managed in a unit with a lower daytime nurse:patient ratio (χ(2)=17.17, p=0.001). Larger units were more likely to use commercial wrist restraints and smaller units were more likely to have a restraint policy, although these results did not reach significance. As an initial exploration, this study provides evidence of the range of restraint practice across Units in Europe. Variation in the number of units per country limits generalization of findings. However, further examination is needed to determine whether there is a causal element to these relationships. Attention should be paid to developing evidence based guidelines to underpin restraint practices., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Aim: To identify the effect of an ICU Liaison Nurse (LN) on major adverse events in patients recently discharged from the ICU., Methods: Case-control study using a chart audit protocol to assess controls retrospectively and cases prospectively. Controls did not receive ICU-based follow-up care. Cases received at least three visits over 3 days from the ICU LN. The LN service operated 7 days/week 0800-1800. Data on a range of predictors and three major adverse events (unexpected death, surgical procedure needed, and transfer to a higher level of care) were collected using a purpose built audit form., Results: A total of 388 patients (201 controls and 187 cases) were included in the study. Demographic and clinical characteristics were similar for both groups. A total of 165 major adverse events were identified in 129 patients. After controlling for all other potential predictors, patients who received the LN intervention were 1.82 times more likely to be transferred to a higher level of care (P=0.028) and 2.11 times more likely to require a surgical procedure (P=0.006). Surgical patients were 7.20 times as likely to require a surgical procedure (P<0.001)., Conclusions: Our results support the claim that ICU LN has a role in preventing adverse events. However as the control data was retrospective and the study was conducted at one site, other unknown factors may have influenced the results., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Aim: To determine activities and outcomes of intensive care unit Liaison Nurse/Outreach services. The review comprised two stages: (1) integrative review of qualitative and quantitative studies examining intensive care liaison/outreach services in the UK and Australia and (2) meta-synthesis using the Nursing Role Effectiveness Model as an a priori model., Background: Acute ward patients are at risk of adverse events and patients recovering from critical illness are vulnerable to deterioration. Proactive and reactive strategies have been implemented to facilitate timely identification of patients at risk., Design: Systematic review., Methods: A range of data bases was searched from 2000-2008. Studies were eligible for review if they included adults in any setting where intensive care unit Liaison Nurse or Outreach services were provided. From 1423 citations and 65 abstracts, 20 studies met the inclusion criteria., Results: Intensive care liaison/outreach services had a beneficial impact on intensive care mortality, hospital mortality, unplanned intensive care admissions/re-admissions, discharge delay and rates of adverse events. A range of research methods were used; however, it was not possible to conclude unequivocally that the intensive care liaison/outreach service had resulted in improved outcomes. The major unmeasured benefit across all studies was improved communication pathways between critical care and ward staff. Outcomes for nurses in the form of improved confidence, knowledge and critical care skills were identified in qualitative studies but not measured., Conclusion: The varied nature of the intensive care liaison/outreach services reviewed in these studies suggests that they should be treated as bundled interventions, delivering a treatment package of care. Further studies should examine the impact of critical care support on the confidence and skills of ward nurses., Relevance to Clinical Practice: Advanced nursing roles can improve outcomes for patients who are vulnerable to deterioration. The Nursing Role Effectiveness Model provides a useful framework for evaluating the impact of these roles.

It is widely acknowledged that many critically ill patients are managed outside of designated critical care units. One strategy adopted in Australia and England to assess and manage risk in these patients is the intensive care unit (ICU) outreach or liaison nurse service. This article examines how ICU outreach/liaison roles in Australia and England operate in the context of Manley's theoretical framework for advanced nursing practice. Descriptive case study design using semi-structured interviews and job descriptions as sources of evidence. Findings of interviews with six Australian ICU Liaison nurses are already published; this study replicated the Australian study with four ICU Consultant Nurses in England and mapped interview and job description data from both countries onto Manley's conceptual framework for advanced practice/consultant nurse. Four themes emerged from the English data: patient interventions, support for ward staff, liaison between ward and ICU staff and hospital-wide impact. The first three of these comprised the core service common to the roles in both countries. Manley's four subroles (expert practitioner, consultant, educator and researcher) were present across both countries. However, the interview and job description data demonstrated that there were lower expectations in Australia that the roles would lead to staff development and build capacity across the hospital system. Similarly, formal education for ward staff such as ALERT and CRiSP courses were more developed in UK. Our data demonstrate that the role undertaken in England and Australia is sufficiently comparable to use as a research intervention in international studies across the two countries. However, the macro service level differs. Job descriptions across both countries emphasized the need to influence hospital policy; however, the ICU consultant nurses in England might be considered better placed to achieve this through role title and access to the hospital executive. In both countries, the roles would benefit from systematic evaluation of the impact on outcomes. This is particularly important for longer-term integration of the role in the health services in both countries.

The mismatch between intensive care unit (ICU) bed availability and demand may be improved with timely patient discharges, however little is known about the nature and contributing factors of discharge delays. This study investigated the impact of a specific intervention--the ICU liaison nurse role--in reducing ICU discharge delay using a prospective block intervention study. One hundred and eighty-six ICUpatients (101 control and 85 liaison nurse intervention) with an ICU length of stay of three days or longer and who survived to ICU discharge were examined. The liaison nurse was involved in assessment of patients for transfer to the ward, with a major focus on coordinating patient transfer including liaison with ward staff prior to and following ICU discharge. Logistic regression was used to quantify the risk of discharge delay associated with the liaison nurse intervention with adjustment for potential confounding variables. While no demographic or clinical variables were significant predictors of ICU discharge delay, those in the liaison nurse group were almost three times less likely to experience a discharge delay of at least two hours and about 2.5 times less likely to experience a delay of four or more hours. The positive effect of the liaison nurse role in reducing the discharge delay remained after adjustingforpotential confounders. We conclude that the liaison nurse role is effective in reducing the discharge delay in ICU transfer

In the UK, recent policy guidelines emphasize the role of nurses in managing the minute-by-minute care of critically ill patients (Department of Health 1996). This article reports on a study that explored the extent to which the nurse at the bedside (the allocated nurse) and the nurse in charge of the shift (the shift leader) make decisions about the needs of children who are critically ill. The study also identified areas of need using a modified Delphi study and explored how nurses perceive and act on the needs of critically ill children. These aspects are presented elsewhere.

Intensive care nurses are an expensive and scarce resource. The internal market within the National Health Service requires greater scrutiny of expenditure in all areas, not least staffing. Inevitably questions are raised regarding the evidence to justify the nurse:patient ratios in specialist areas such as intensive care. This paper addresses some of the issues surrounding staffing in intensive care and discusses the impact of changes in medical practice on the nursing role. The nurse:patient ratio is lower in the USA, therefore a brief comparison between the two countries is provided in order to inform discussion and debate. The importance of these issues for all intensive care nurses is emphasised, together with a plea for a substantive study to provide evidence of nursing work and inform future decision-making by the purchasers and providers of intensive care services.